A 0h/1h protocol for safe early discharge of chest pain patients

Abstract

Objectives

Guidelines recommend a 0h/1h high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There is however little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0h/1h hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and ECG for ruling out major adverse cardiac events (MACE) within 30 days.

Methods

This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0 and 1h hs-cTnT were collected. 30-day MACE was defined as acute myocardial infarction, unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular-block, cardiac arrest or death of cardiac or unknown cause.

Results

A total of 1020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a non-ischemic ECG, and either a 0h hs-cTnT <5 ng/L, or a 0h hs-cTnT <12 ng/L combined with a 1h increase <3 ng/L, identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% CI: 98.3 – 99.9) and a negative likelihood ratio of 0.04 (95% CI: 0.01 – 0.14) for 30-day MACE. The ADP missed only 2 patients with UA and no patients with AMI or other forms of MACE.

Conclusion

An ADP using the guideline recommended 0h/1h hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.

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